Ambiguous Mammogram Sparks Quest for Answers

A 46-year-old woman goes in for a mammogram because she dreamed there was a seed in her left breast. “It looked somewhat like a watermelon seed… it could open up like a dandelion and then I would have little black flecks all through my breast,” Marla Brin writes in this morning’s Washington Post.

The real-life mammogram reveals a “white spot where it was not supposed to be.” Brin has dense breasts, which tend to render mammograms less definitive. So the radiologist recommends having another one in four to six months.

She worries and doesn’t want to wait. And she’s up on the medical literature, which counsels the importance of getting an impartial second opinion for cancer. An oncologist friend advised her to get an MRI, which proves difficult. Her gynecologist dismisses the dream and the equivocal mammogram and also advises her to wait.

Brin perseveres, tapping well-connected friends to help her navigate the medical maze. “This journey has really opened my eyes,” she writes. “Even with all my advantages, I still have had to fight for the health care I have been told is best for me.”

She ultimately gets her second opinion, “a more definitive test” and learns that the spot was simply a lymph node that wasn’t cancerous. She concludes that she was right to fight for the second opinion and the peace of mind it brought. But the quest was daunting and required resources and insights many people might not have.

Comments (5 of 6)

The main problem is that for every story of a woman whose life could've been saved by an additional test - I say could've because nobody can say for sure if a specific delay made a difference in final outcome - there are many women who end up having unnecessary biopsies or even unnecessary treatment (overdiagnosis). And that has very serious risks too.

Let's look at the numbers. After 10 years of yearly mammograms over half of the women screened would have at least one false positive (less in Europe), 25% of these false positives will result in biopsy - I am using numbers listed on NIH PDQ website. Only a small percentage of those will result in cancer diagnosis and only in a small subset of these cancers early diagnosis would make a difference: some are still curable when detected later,and some are too aggressive and will kill anyway.

If every single case of an ambiguous or suspicious results is investigated further, half of the women may end up having at least one biopsy. Moreover, the risk of overdiagnosis is likely to increase as well. Would less women die of breast cancer? Probably. But biopsies have risks too. Unnecessary treatment has even greater risks. When the probability of a woman benefitting from extra tests is small, even a small probability of harm is significant.

7:59 pm March 27, 2007

S.E. wrote :

Just two months after a mammogram and an "all clear" I discovered a lump in my breast. I had to wait over a month before I could get another mammogram, which proved inconclusive. An ultrasound was also inconclusive. A needle biopsy, inconclusive. At each step I was told to go home and not to worry. Finally, almost three months after I first felt the lump, I was told I had breast cancer. During the course of my treatment (mastectomy and chemo) I met many other women with similar stories. It was news to all of us that mammograms can miss up to 20% of breast cancers. I encourage all my female friends to do self exams. I'm afraid that very few women actually do. It's scary to confront your mortality on a monthly basis. So, how about checking yourself out once every change of season? It could save your life.

4:16 pm March 27, 2007

More tests does not equal better medicine. wrote :

This story perpetuates the popular fallacy that "more tests = better medicine".

A benign finding, like this one, simply led to an unnecessary, expensive, test for the patient's peace of mind.

Should we obtain a breast MRI for every suspicious mammogram? Mammograms are not 100% diagnostic, and there are significant gray areas in mammogram interpretation.

There are zero studies suggesting a mortality benefit of a breast MRI.

So, in the end, obtaining a breast MRI was simply for peace of mind. Which is fine, if that's what the patient wants - and understands the risks they are taking by overtesting.

However, can health care costs continue to sustain continued, expensive tests, simply for peace of mind?

The hard truth is that no test or diagnosis is 100% accurate, no matter how many second opinions, or expensive tests, one obtains.

That is a hard truth that the public has to accept.

4:07 pm March 27, 2007

Dave Howser wrote :

And you're a perfect example of what's wrong with some doctors, ignoring their patients wishes and considering it "pandering." Others would call it an empowered patient. Go back to practicing in the dark ages.

3:03 pm March 27, 2007

happyman wrote :

so in the end, her initial doctors advising "wait and see" were right and she was wrong.

that's why pandering to patient demands makes healthcare so expensive. "doctor" brin should be made to pay for the MRI; and what business does her friend the oncologist have in advising her to get an MRI when that isn't standard of care, and she's not her treating physician?